Author ORCID Identifier

https://orcid.org/0000-0002-7345-9731

Year of Publication

2019

Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation

College

Medicine

Department

Behavioral Science

First Advisor

Dr. Peter E. Morris

Second Advisor

Dr. William W. Stoops

Abstract

While early fluid resuscitation may be a necessary component to decrease mortality in the majority of critically ill patients admitted to the intensive care unit, the benefit of continued administration after the first 24 hours is less clear. Paradoxically, a positive fluid balance secondary to intravenous fluid receipt has been associated with diverse and persistent perpetuating detriment on a multitude of organ systems. Continued clinical harm has been demonstrated on pulmonary and renal function as well as patient outcomes such as rates of mortality and length of stay. Despite the growing body of evidence supporting the potential adverse aspects of positive fluid balances, fluid overload remains common in patients during the early days of critical care admission.

One approach to correcting fluid balance is shifting focus onto the post- or de- resuscitation period with appropriate fluid removal with diuresis once hemodynamic stability is achieved. However, diuresis is often ineffective due to a lack of standardization in identification of fluid-overloaded patients. Further, optimal transition times between fluid resuscitation and fluid removal are not clear and physical signs of fluid overload are delayed relative to onset of organ damage. While administration of diuretics has shown to decrease net volume and improve clinical outcomes in the critically ill, current practice does not reflect clinical trial findings. Most treatment regimens are often inadequate both by nature of time and dosing intensity. Further, as de-resuscitation occurs once the initial instability has resolved, precedence is usually given to other acute or critical needs rather than follow-up for diuresis effectiveness. Additionally, frequent apprehension for medication side effects is seen, despite the preponderance of adverse event data found only in non-critical care populations, frequently non-translatable to patients within the intensive care unit.

Optimization of diuresis in critically ill patients is primed for clinical pharmacy intervention. Clinical pharmacists are experts in the delivery of pharmaceutical care, utilizing specialized therapeutic knowledge, experience, and judgment to ensure optimal patient outcomes. Pharmacist-driven protocols for other conditions have shown improved patient outcomes, reduced adverse events and improved target attainment in before and after studies. A pharmacist- driven diuresis protocol to facilitate de-resuscitation implemented within the multidisciplinary critical care team has the potential to improve patient care by optimizing pharmacotherapy selection, while potentially reducing adverse events, days on mechanical ventilation and length of intensive care unit stay. Such a protocol rightfully places pharmacist accountability on medication-related outcomes while potentially decreasing critical care resource utilization.

The work within this dissertation aims to accomplish the development of a pharmacist- driven diuresis protocol for implementation in the medical intensive care unit, with national pharmacy organization sponsorship. Further, the protocol aims to be adopted as an innovative practice change for de-resuscitation of critically ill patients to improve clinical outcomes while advancing the pharmacy profession.

Digital Object Identifier (DOI)

https://doi.org/10.13023/etd.2019.122

Funding Information

American Society of Health Systems Pharmacists

Available for download on Monday, May 03, 2021

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